Trauma History Screen – Child 20210610 Client Name* First Last Client Date of Birth* MM slash DD slash YYYY Today's Date* MM slash DD slash YYYY Directions: Ask how many times each event happened, and how much it affected the child when it happened and now. How many times has this happened?1. Have you ever been in or seen a very bad accident?* Never Once 2-3 times 4-10 times 10 – times 2. Have you ever had someone you know been so badly injured or sick s/he almost died?* Never Once 2-3 times 4-10 times 10 – times 3. Have you ever known somebody who died?* Never Once 2-3 times 4-10 times 10 – times 4. Have you ever been so sick or hurt that you or the doctor thought you might die?* Never Once 2-3 times 4-10 times 10 – times 5. Have you ever been unexpectedly separated from someone you depend on for love or security for more than a few days?* Never Once 2-3 times 4-10 times 10 – times 6. Have you ever had somebody close to you tried to kill or hurt themself?* Never Once 2-3 times 4-10 times 10 – times 7. Have you ever been physically hurt or threatened by someone?* Never Once 2-3 times 4-10 times 10 – times 8. Have you ever been robbed or seen someone get robbed?* Never Once 2-3 times 4-10 times 10 – times 9. Have you ever been kidnapped by somebody?* Never Once 2-3 times 4-10 times 10 – times 10. Have you ever been in or seen a hurricane, earthquake, tornado, or bad fire?* Never Once 2-3 times 4-10 times 10 – times 11. Have you ever been attacked by a dog or other animal?* Never Once 2-3 times 4-10 times 10 – times 12. Have you ever seen or heard people physically fighting or threatening to hurt each other?* Never Once 2-3 times 4-10 times 10 – times 13. Have you ever ever seen or heard somebody shooting a gun, using a knife, or using another weapon?* Never Once 2-3 times 4-10 times 10 – times 14. Have you ever seen a family member arrested or in jail?* Never Once 2-3 times 4-10 times 10 – times 15. Have you ever had a time in your life when you did not have the right care (e.g. food, clothing, a place to live)?* Never Once 2-3 times 4-10 times 10 – times 16. Have you ever been forced to see or do something sexual?* Never Once 2-3 times 4-10 times 10 – times 17. Have you ever seen or heard someone else being forced to do something sexual?* Never Once 2-3 times 4-10 times 10 – times 18. Have you ever watched people using drugs (like smoking, sniffing, or using needles)?* Never Once 2-3 times 4-10 times 10 – times 19. Have you ever seen something else that was very scary or where you thought somebody might get hurt or die?* Never Once 2-3 times 4-10 times 10 – times If yes to #19, explain*The worst time this happened, how much did it affect you?1. Been in or seen a very bad accident?* Not at all A little bit Moderately Quite a bit Extremely 2. Had someone you know been badly injured or sick that s/he almost died?* Not at all A little bit Moderately Quite a bit Extremely 3. Known somebody who died?* Not at all A little bit Moderately Quite a bit Extremely 4. Been so sick or hurt that you or the doctor thought you might die?* Not at all A little bit Moderately Quite a bit Extremely 5. Been unexpectedly separated from someone who you depend on for love or security for more than a few days?* Not at all A little bit Moderately Quite a bit Extremely 6. Had somebody close to you tried to kill or hurt themself? Not at all A little bit Moderately Quite a bit Extremely 7. Been physically hurt or threatened by someone?* Not at all A little bit Moderately Quite a bit Extremely 8. Been robbed or seen someone get robbed?* Not at all A little bit Moderately Quite a bit Extremely 9. Been kidnapped by somebody?* Not at all A little bit Moderately Quite a bit Extremely 10. Been in or seen a hurricane, earthquake, tornado, or bad fire?* Not at all A little bit Moderately Quite a bit Extremely 11. Been attacked by a dog or other animal?* Not at all A little bit Moderately Quite a bit Extremely 12. Seen or heard people physically fighting or threatening to hurt each other?* Not at all A little bit Moderately Quite a bit Extremely 13. Seen or heard somebody shooting a gun, using a knife, or using another weapon?* Not at all A little bit Moderately Quite a bit Extremely 14. Seen a family member arrested or in jail?* Not at all A little bit Moderately Quite a bit Extremely 15. Had a time in your life when you did not have the right care (e.g. food, clothing, a place to live)?* Not at all A little bit Moderately Quite a bit Extremely 16. Been forced to see or do something sexual?* Not at all A little bit Moderately Quite a bit Extremely 17. Seen or heard someone else being forced to do something sexual?* Not at all A little bit Moderately Quite a bit Extremely 18. Watched people using drugs (like smoking, sniffing, or using needles)? Not at all A little bit Moderately Quite a bit EXtremely 19. Seen something else that was very scary or where you thought somebody might get hurt or die?* Not at all A little bit Moderately Quite a bit Extremely If yes to #19, explain*How much does this STILL affect you?1. Been in or seen a very bad accident?* Not at all A little bit Moderately Quite a bit Extremely 2. Had someone you know been so badly injured or sick that s/he almost died?* Not at all A little bit Moderately Quite a bit Extremely 3. Known somebody who died?* Not at all A little bit Moderately Quite a bit Extremely 4. Been so sick or hurt that you or the doctor thought you might die?* Not at all A little bit Moderately Quite a bit Extremely 5. Been unexpectedly separated from someone who you depend on for love or security for more than a few days?* Not at all A little bit Moderately Quite a bit Extremely 6. Had somebody close to you tried to kill or hurt themself?* Not at all A little bit Moderately Quite a bit Extremely 7. Been physically hurt or threatened by someone?* Not at all A little bit Moderately Quite a bit Extremely 8. Been robbed or seen someone get robbed?* Not at all A little bit Moderately Quite a bit Extremely 9. Been kidnapped by somebody?* Not at all A little bit Moderately Quite a bit Extremely 10. Been in or seen a hurricane, earthquake, tornado, or bad fire?* Not at all A little bit Moderately Quite a bit Extremely 11. Been attacked by a dog or other animal?* Not at all A little bit Moderately Quite a bit Extremely 12. Seen or heard people physically fighting or threatening to hurt each other?* Not at all A little bit Moderately Quite a bit Extremely 13. Seen or heard somebody shooting a gun, using a knife, or using another weapon?* Not at all A little bit Moderately Quite a bit Extremely 14. Seen a family member arrested or in jail?* Not at all A little bit Moderately Quite a bit Extremely 15. Had a time in your life when you did not have the right care (e.g. food, clothing, a place to live)?* Not at all A little bit Moderately A quite bit Extremely 16. Been forced to see or do something sexual?* Not at all A little bit Moderately A quite bit Extremely 17. Seen or heard someone else being forced to do something sexual?* Not at all A little bit Moderately Quite a bit Extremely 18. Watched people using drugs (like smoking, sniffing, or using needles)?* Not at all A little bit Moderately Quite a bit Extremely 19. Seen something that was very scary or where you thought somebody might get hurt or die?* Not at all A little bit Moderately Quite a bit Extremely If yes to #19, explain20. Which one of these bothers you the MOST right now, and how long ago did it happen?* Please click SUBMIT when complete
